Treatment

The main aim of insomnia management is to improve sleep quantity and quality, improve daytime function (greater alertness and concentration), and cause minimal adverse drug effects

Acute insomnia

• address the trigger factors which might have resulted in insomnia e.g. – ill health, stress, medication, change in time zone etc.
• provide with or review sleep hygiene practices
• educate and reassure the patient that the symptoms are usually self limiting and are usually caused by a precipitant factor
• short term hypnotic can be considered if symptoms are severe and causes distress about lack of sleep
• if there is no improvement consider comorbid conditions

Chronic insomnia

• healthcare professionals should address any relevant, underlying problems :
  • prescribed drugs (eg some antidepressants, withdrawal of sedatives) and non-prescribed drugs (eg caffeine, alcohol)
  • physical - pain, respiratory and cardiovascular disorders, neurological disorders, movement disorders, restless leg syndrome and other sleep disorders)
  • psychiatric disorders - depression, anxiety, dementia and substance misuse)
  • disruption of circadian rhythm - shift work)
• first-line therapy should be non-drug therapy - cognitive behavioural therapy (CBT)
• in patients with significant distress and impact on waking function due to insomnia consider pharmacological treatment (should be used in parallel with non drug treatment and need regular review of medication)
• manage comorbid conditions and refer to a specialist if indicated

Secondary insomnia is treated via treatment of the primary condition.

Whether acute or chronic insomnia, the following non-pharmacologic and pharmacologic treatments can be utilised for treatment (depending on the individual patient and circumstances).

Non paharmacological therapy

• cognitive behavioural therapy (CBT)
  • sleep hygiene
  • stimulus control
  • sleep restriction
  • relaxation training
  • cognitive restructuring (4)

Pharmacological therapies include (4,5)

• benzodiadepine and Z drugs
• melatonin
• antidepressants
• antipsychotics
• sedating antihistamines

Herbal remedies (5)

• stated that there is insufficient evidence to support the use of herbal medicine for insomnia, though there is a clear need for further research in this area

Reference:

• (1) Cunnington D, Junge M. Chronic insomnia: diagnosis and non-pharmacological management. BMJ. 2016;355:i5819.
• (2) Falloon K et al. The assessment and management of insomnia in primary care. BMJ. 2011;342:d2899.
• (3) Ramakrishnan K, Scheid DC. Treatment options for insomnia. Am Fam Physician. 2007;76(4):517-26.
• (4) Kay-Stacey M, Attarian H. Advances in the management of chronic insomnia. BMJ. 2016;354:i2123
• (5) Wilson S et al. British Association for Psychopharmacology consensus statement on evidence-based treatment of insomnia, parasomnias and circadian rhythm disorders: An update. J Psychopharmacol. 2019 Aug;33(8):923-947
• (6) Leach MJ, Page AT. Herbal medicine for insomnia: A systematic review and meta-analysis.Sleep Med Rev. 2015 Dec;24:1-12